Health Information Network and Tele-health centers support

This is a continuing activity from FY06. The partner has received 100% of FY06 funding and is on track according to the original targets and workplan. We have also increased FY07 funding based on the achievements from FY06. Tulane University/UTAP is supporting MOH to establish health information network and Tele-health centers. A National Computer Resources Mapping Survey was conducted to map out all of the woredas where the Government of Ethiopia high-speed communications network is located, human resource capacity, hardware and software resources. The information gathered helps identify the availability of Information and Communication Technology (ICT) infrastructure and resources for use of tele-health and distance learning technologies that will directly support improved quality of care and treatment throughout the health network.

In FY06 the support includes the implementation of technology learning resource centers at the two universities (Defense-AFGH, Health Science College and Air force ART clinic, Jimma University) and at MOH. These centers have a networked classroom facility that supports up to 30 students, with individual computers. The classroom system had fast internet connectivity that supports distance learning applications for both individuals and groups. In addition, each of these three sites has a smaller video-conferencing center to support conferences and tele-consultation. This activity also developed and deployed on a pilot basis tele-health applications at Jimma University and selected health centers. This has been done in collaboration with PEPFAR Ethiopia and the US Army Telemedicine and Advanced Technologies Research Center (TATRC) using TATRC provided non-PEPFAR funds. Initial applications focused on tele-consultations, surveillance, and patient referral.

In FYO7, Tulane University in collaboration with TATRC will continue to support the expansion of tele-consultation and information sharing from the lowest health structure to the MOH, in five centers,, EHNRI, DACA, Mekele, and Debub Universities including PEPFAR supported Technology Assisted Learning Centers hospitals by establishing Local Area Network and Wide Area Network systems. Additional support not covered in FY06 that is necessary to maximize the use of the learning centers, will be covered in FY07. All centers will have the capacity to support 30 users at one time in technology assisted learning centers that will include video-conferencing depending on connectivity at each site.

This activity, by leveraging Global Fund and other resources, will enable video-conferencing at five RHB in order to strengthen information sharing between MOH and to strengthen the ART data reporting system at all levels. This directly supports the MOH identified need for expansion of efficient telecommunications within regions with an aim of improving surveillance and patient care. Video conferencing will also eliminate the considerable time taken to reach meetings by personnel from remote areas.

In FY07, gaps identified by the National Computer Resources Mapping survey on connectivity of MOH with RHB and health facilities will be also addressed. This activity will leverage Global Fund funds for hardware distribution for RHB, woredas and health facilities and will supplement any additional gaps identified in the survey.

deleted per PHE and program reviews

Development of Healthcare Data warehousing and Electronic Medical Record System

These are two continuing activities (5724, 1095) from FY06 and are linked with activities of national HMIS support, strengthening of national M&E (5582), surveillance (5717, 5585) and clinical records (5685). The partner is on track according to the original targets and work plan and has received 100% of FY06 funding. FY07 funding is increased because of performance to date.

In FY06 the National Computer Resources Mapping Survey was conducted to map the districts where the Government of Ethiopia high-speed communications network (funded by World Bank) is located, their human resource capacity, and hardware and software resources. The information gathered will help to identify the availability of Information and Communication Technology (ICT) infrastructure and resources for the implementation of the data warehouse and Electronic Medical Record (EMR).

In this activity there are two sub activities: development of an electronic medical records system to support HIV/AIDS care and treatment-related activities at health facilities, and the design and development of a data warehouse for MOH and RHB that includes strengthening the GIS and spatial analysis in health.

Electronic Medical Record (EMR) The MOH is expanding ART services rapidly and needs a robust patient information system that improves care and programming. The MOH, facing the challenge of improving the quality of ART services while also rapidly scaling up capacity, is trying to ensure that ART patients are not lost to follow up and their medical information is not lost as they visit various clinics over time and distance. An EMR, a relatively new technology, is a complement to the National Health Management Information System (HMIS), wherein quality medical service provision is made, recorded, and tracked at the individual level. Using an electronic medical record, recording and tracking of each individual's care, as well as collective or aggregate patient information for HMIS purposes, becomes possible. For clinics using an EMR system, many HMIS indicators can be produced automatically, without further burden to staff. It is a system needed to assure continuity of patient care over time, place, across types of service and levels of care. It enables the standardization and collection of health information data that can be used for decision making. It also enables timely data capture at a point of care as well as data access and reuse at a subsequent point of service, hence improving quality of care and reducing costs of repeated tests. Furthermore, it can produce "real-time" reports on indicators such as patient count by sex and age categories and geographic distributions, longitudinal cohort data, health demographics, adherence and cost statistics, which are accurate, valid, reliable and timely. It also helps in de-duplication of patient counts and linking of patient information to currently separate ‘vertical' paper systems such as TB, HIV/ART, ANC, PMTCT, VCT, STI, and thus improving the efficiency of decision making. Once individual data are electronic, the subsequent burden of manual aggregation for HMIS reporting, and the subsequent occurrence of human errors is reduced.

This project involves storing personal health information on a secure memory card device (smart card) and giving it to the patient to present to the clinician whenever they seek care. This data is the patient electronic medical record, a copy is kept at facilities visited -- for purposes of backup and HMIS use. Since the patient data is on the smart card it does not require a communication infrastructure to transfer patient information form one point of care to another.

In FYO6, a demonstration of the Zambian experience in system development and implementation of EMR was conducted for MOH and major stakeholders. The system was fully approved for adaptation within Ethiopia. With the involvement of Zambian software development team, customization of the application for Ethiopia was initiated in FY06. Tulane University with guidance from EMR project experts in Zambia, is responsible for building the system.

In FY07, based on the experience from the pilot, the EMR implementation is expected to start at 35 ART networks. The system will cover all patients enrolled in comprehensive ART services as well as mothers attending ANC and receiving PMTCT, and spouses seeking VCT. The inclusion of ANC services is to reduce the possible stigmatization of the smart

card that might occur if the EMR is used only for those patients who are taking ART.

The program requires a significant initial investment in hardware including: computers and monitors; UPS (uninterruptible power supplies); printers (for all 35 facilities and Woreda health offices); and selected servers, and the installation of networks. Consumables budgeted include paper, toner, and smart cards. Adaptation of the software to the Ethiopian context will also continue and will draw technical assistance from other countries which are implementing such a system. Costs related to these activities include: the recruitment and salary of new software programmers, salary for data clerks as needed; training on the use of the system, and a series of staff sensitization interventions at the facilities selected for implementation of the system.

The data flow between the EMR system at facilities and the HMIS system at the facility, Woreda, and regional levels will also be implemented. The continuation of seconded international and national staff to MOH will be a component of this activity.

Data Warehouse and Re-design of MOH Web Sit The data warehouse is a central data repository that collects, integrates and stores national data with the aim of producing accurate and timely health information that supports evidence based data analysis and reporting on HIV/AIDS care, treatment and prevention.

Relevant sources for the data warehouse include the national M&E program reports, population based surveys, non-identifiable aggregated data from EMR and data from the national HMIS routine reporting.

In FY07 technical assistance will be provided to MOH on the design, data architecture and database development of the HIV/AIDS information system based on the National HMIS strategy. This system includes routine and survey information on HIV/AIDS and other related diseases from various government organizations, NGOs, research institutions and the private health sector. The assistance will also include re-designing the MOH website that links to the data warehouse for data mining, data analysis and report. Training will be conducted to MOH staff to maintain the web site.

In FY07 the national data warehouse and GIS capacity building activity will expand to 5 regions. The support includes human resource capacity building, hardware acquisition, and software licensing and application development.

National Monitoring and Evaluation System Strengthening and Capacity-Building

This is a continuing activity from FY05 and FY06 and it includes activity #5582, 1090, 1094, and 5714. It is linked to prevention, care and treatment programs, as well as development of healthcare data warehousing, electronic medical record system (5724), site level data support (1080, 1082, 1083, 1096 and 1116), health information network, and tel-health centers support (5687). The development of the National HIV/AIDS M&E system is a sub-set of the comprehensive HMIS strategy and master plan being developed by the Ministry of Health. As of August 2006, the partner received 100% of FY06 M&E stream funds and is on track according to the original targets and work plan. With the TA support provided by Tulane University, Ethiopia has become the only Sub-Saharan African country that has implemented one national monitoring system for all ART facilities. Tualane in collaboration with Jimma University (JU), launched the first postgraduate Health M&E post graduate diploma/MSc program in Africa. The introduction of this innovative program is cost-effective in building a sustainable national capacity as opposed to sending students abroad. Brain drain is also minimized as each trainee signs a two year contract to work in the public health system.

In the past, Ethiopia suffered from a poorly functioning manual data collection and reporting that lacked standardized indicators and formats. Reports are untimely and often incomplete. While efforts to improve are being made within MOH, the need for technical assistance and support for an HMIS and M&E system and human capacity development is evident. PEPFAR Ethiopia recognizes this need and supports in its five-year-plan the goal of the Third One i.e. Building One National M&E" system. In FY06, technical assistance was provided to MOH/HAPCO to develop national HMIS/M&E strategies and guidelines with a focus on HIV/AIDS indicators, design/revision of standardized data collection instruments, development of standard operating procedures for health center ART services linked to hospitals, and standardized intra/inter-facility referral forms. Guides on how to use formats and procedures were developed for care, treatment, and prevention service providers. With MOH and partners, Tulane revised HIV/AIDS and related diseases reporting formats. Support also included technical assitance to HAPCO to develop M&E training modules for grassroots level and support to MOH/HAPCO/EHNRI to expand comprehensive HIV/AIDS patient monitoring services to the Woreda health center s to reach into the communities. M&E specialists were seconded to the M&E unit of the MOH/HAPCO. Short-term training programs, e.g. use of data for decision-making and other related trainings, were provided to MOH/HAPCO to improve the M&E knowledge and skills at the national and regional levels.

Major FY07 M&E system development activities were planned after detailed consultation with MOH/HAPCO that are need based and build on previous work by Tulane. Tulane will continue to work with MOH to further develop the "One M&E" system to gather quality data. In FY07 the national M &E system will roll out to the community level and the standard operating procedures for health center ART services linked to hospitals, and standardized intra/inter-facility referral forms will be implemented all the way from community-health centers-hospitals-district-region-national levels. Tulane will continue assisting MOH in identifying core health indicators for HMIS reporting and improving capacity to collect patient level information to assist with service delivery at all levels.

In FY07 HIVQUAL will be extended to 35 HIV service networks. Tulane will provide TOT on HIVQUAL Ethiopia from all regions and link it to the development of the national EMR. Support will be provided to district health teams in four regions to apply tools developed at the national level and institutionalize training and continue to support FMoH and regions by short and long term consultants. Tulane will also integrate HIVQUAL Ethiopia benchmark reports into the annual M&E report. The seconding of M&E specialists to MOH, HAPCO and EHNRI M&E units will continue. The M&E mentorship program will be extended to include the 131 ART networks. The short term M&E training programs will be extended by conducting skill building workshops on data use, analysis, audits, triangulation and advocacy to cover regions. The monthly, quarterly and annual M&E update bulletins will continue to be produced and disseminated to all partners. The scientific writing workshops will be offered to a larger audience (30 people) at MOH/HAPCO and regions. TOT will be initiated and cascaded to all regions. Participants will be supported to publish work in a peer review journal. Technical assistance will be provided to MOH/HAPCO to create a system and link activity and financial monitoring

mechanism to track money spent by HAPCO on HIV/AIDS, based on the national M&E budget road map.

Human Capacity Development (5714) Tulane University in collaboration with Jimma University (JU) had launched the first postgraduate Health M&E Post Graduate Diploma/MSc program in Africa. The first batch of 31 M&E students whose formal class commenced in February 2006 have now completed two out of three blocks of courses required for their first year academic completion. The second class of 40 M&E students is scheduled to start class in January 07. In addition, in FY06 support to Jimma University includes both technical and resource assistance for the training of 100 HMIS cadres, this has exceeded the target set for that year. In FY06, the institutional support to JU included joint appointment of academics, support of course coordinator and administrative staff and support of the program with technical assistance and provision of audio-visual equipment including wireless internet access to M&E teaching staff and students, website development, production of teaching materials and capacity building through distance learning by working closely with Tulane's Payson Center and FIOCRUZ, Brazil. Teaching materials of HMIS/M&E courses at JU are being converted into e-materials to extend coverage to a much larger audience from the government, NGO/FBO community as well as to promote sustainability of the training program including offering M&E courses using distance learning.

The support to JU MSc program will continue in FY07. The graduates will be the basis of the newly forming Ethiopia M&E Network, which provides a forum for sharing ideas and experiences and mentor RHB, NGOs, FBOs and other local stakeholders. Technical assistance and support to JU will continue for the pre-service I year HMIS training program for building sustainable M&E systems at the service facilities (for a combined FY06- 07 total of 200). Support will continue to be given to JU to produce and disseminate M&E training materials required for the delivery of courses. All materials produced for the certificate and diploma HMIS course at JU will be converted into e-materials. In FY07, Tulane will support JU to embark on distance learning course for M&E by learning from experience of such course from Brazil. Organization inside and outside the country will be able to sponsor students to these programs. This preparation will help JU to extend training to a much larger number of students and thus building a state-of-the-art training program for HMIS officers. Tulane will continue integrating M&E training in the pre-service training in the Accelerated Health Officers training program. A summer institute for faculty for training and sharing experience will be established. As JU has critical shortage of teaching staff two assistant lecturers amongst the first M&E cohorts will be recruited as part of staff retention mechanism at JU.

Human Resource Requirement for Meeting Targets by 2010

This is a new targeted evaluation activity in FY07. The roll out of free ART was initiated in January 2005 with the support of PEPFAR and the Global Fund. Ethiopia is committed to the global initiative on Universal Access to HIV/AIDS 2010 and MDG 2015. In 2005 the number of people who need ART is estimated to be 277,757 including 24,201 children, this number is expected to increase to 330,775 people by 2010. To meet this target, MOH is implementing massive ART scale up. The most prominent challenge to this scale up is a human resource shortage. This targeted evaluation will explore the human resource requirements for meeting PEPFAR and Universal Access by 2010.

There are twoo evaluation questions. The first is what is the gap in the human resource requirement for meeting PEPFAR and Universal Access targets by 2010? The second one is what strategies and innovative solutions should be adopted if the country is to meet these targets?

The study will lay out recommendations and possible alternative solutions to meet the human resource shortage in ART scale up and address the health sector workforce crisis the country is facing.

This comprehensive assessment will be based on extensive literature review, documentation of other countries experience and the use of both quantitative and qualitative methods. Representative sample of different categories of decision makers, health workers, trainers, and health managers and will be interviewed. Observations and inventories will be carried out to document the actual workload on health workers and the overall situation at different levels of the health system

The National ART Implementation Guidelines propose that a team of two doctors, a nurse , counselor, one pharmacist, one lab technician administer, and a data clerk are need to manage ART services at a facility. These health care workers will be the population of interest.

Plus ups: PEPFAR Ethiopia will fund Tulane University to support the National AIDS Spending Assessment (NASA) planned for FY07 in coordination with UNAIDS, UNDP and other partners.The main objective of NASA, or HIV/AIDS resource tracking at country level, is to determine what is actually mobilised and spent in the fight against HIV/AIDS and how expenditures were organized, by following the resources flow from origin to final destination (i.e.beneficiaries receiving goods and services). It is systematic, periodic, multiple-vector and exhaustive tracking of actual spending (from international, public and private sectors) that comprises the national response to HIV/AIDS. This data will help PEPFAR to plan and prioritise needs. It establishes standardized reporting on monitoring indicators to assess progress towards achieving targets of the Declaration of Commitment adopted by the United Nations General Assembly Special Session on HIV/AIDS (UNGASS I). NETWORK MODEL ASSESSMENT - PEPFAR Ethiopia supports the Government of Ethiopia in HIV treatment, care and prevention activities throughout Ethiopia. To do this, a generally horizontal health network model has been followed until now, with CDC and its partners supporting comprehensive interventions at national and hospital levels, while USAID and its partners do so at health center and community levels. In a few situations one partner provides vertical support at the hospital and health centers; therefore currently Ethiopia follows a mixed model. The purpose of the USG network model is to support effectively and efficiently the tier of health facilities by providing comprehensive and quality HIV services. It is therefore crucial that the PEPFAR support network works well. To verify this and improve the coverage and quality of care and support at all levels, it has been deemed necessary to assess and monitor the health network model with the aim of improving its mode of support. PEPFAR has supported development of the MOH and EHNRI comprehensive information technology network infrastructure including internet connectivity and website development from FY 05/06. All necessary equipment was procured, donated to GOE and more than 95% of the activity completed. Because of the FMOH and EHNRI restructuring and expansion of activities, their existing LAN system should expand to accommodate additional requirements, including connectivity with regional health bureaus, regional HAPCOs, federal and regional referral hospitals, and district hospitals for improved data

exchange, laboratory data quality control and quality assurances as well as data transfer and reporting. This activity will support upgrade of the current ADSL 128kbps Internet broadband connectivity of EHNRI for better data transmission and communication as well as additional data lines installation both for the Ministry and EHNRI. Through this activity items required to complete the overall project will be procured. "The plus up fund will also be used to conduct requirement surveys and need analyses for regional health bureaus, regional and hospital laboratories and health institutions to identify and document ICT gaps for data-driven capacity-building planning.

The following five sub-activities will be implemented: 1) Procurement of additional IT equipment including servers, software, switches, etc for MOH and EHNRI to enhance their existing LAN/WAN systems to provide regional connectivity 2) ICT related refresher training for relevant existing and new staff including advanced regional ICT training and experience sharing programs for key Ministry and EHNRI SI staff 3) Needs assessment for regional health bureaus, HAPCOs, regional laboratories, and health institutions to produce data for ICT capacity building planning, including human capacity development in the regions. 4) Upgrade of current ADSL 128kbps Internet broadband connectivity of EHNRI to 512kbps 5) Installation and configuration of additional data lines and UPS lines for the Ministry and EHNRI."

PEPFAR Ethiopia will fund Tulane University to support conversion of a spreadsheet-based health program costing tool into database form in order to: 1. Allow rapid costing of kebele, facility, woreda, network, zonal, regional and national HIV/AIDS programs, by multiple parameters; 2. Allow stakeholders to determine total financial needs, amounts committed by partners, and funding gaps, if any; 3. Initially calculate funding needs for HIV/AIDS only; however, the tool will be easily adaptable for use by all portions of the health sector, and should be able to capture community and program level as well as facility-based costs This will assist in determining resource needs for HIV/AIDS decentralization of services, Global Fund and other funding proposals, overall program planning.